Quality Improvement Initiative: Maximizing Dressing Adherence to Minimize Infections

Lee Steere, RN, CRNI, VA-BC™ | Unit Leader, IV Therapy Services, Hartford Hospital

INTRODUCTION

Like all hospitals, our organization is continually focused on optimizing the Institute for Healthcare Improvement’s Triple Aim in order to improve patient care, improve quality and reduce healthcare costs. One way to do this is by minimizing infections, particularly catheter-related bloodstream infections (CRBSIs), as these hospital-acquired infections result in longer hospital stays, increased mortality and significantly higher costs. While no single solution can prevent infections alone, numerous studies show that VAD dressing disruptions are a major risk factor for CRBSIs.1 Evidence-based guidelines from organizations like the U.S. Centers for Disease Control (CDC) and Infusion Nurses Society (INS) recognize the importance of vascular access device (VAD) dressing integrity in minimizing infection risks. The recent paradigm shift from routine to clinically indicated catheter replacement has further increased the importance of protecting insertion sites and making all VADs -- from central to peripheral intravenous (PIV) line -- remain in place longer. Unfortunately, data reveal that dressing disruptions happen far too frequently. We suspected this was the case at Hartford Hospital. Our IV Therapy Services team conducted a trial to test the impact of a gum mastic liquid adhesive on central venous catheter (CVC) dressing integrity. The marked improvement in dressing adherence led to a hospital-wide quality improvement initiative for all central lines to minimize infection risks, improve patient safety and reduce healthcare costs.

DRESSING INTEGRITY IS ESSENTIAL

Proper dressing adherence is an essential part of catheter site care and maintenance. Intact dressings prevent complications like catheter migration, dislodgement and infiltration. Most importantly, preserving dressing integrity can reduce the risk of CRBSIs. According to a 2012 study, the risk of infection increased more than 3-fold after the second dressing disruption, and increased 12fold if the final dressing was disrupted.1

Current guidelines from the INS and CDC define an “unplanned dressing change” as any change that happens within the first seven days -- yet research indicates that dressing disruptions happen with alarming frequency. In 2016, a study of four commercially available CVC dressings showed that the dressings had surprisingly limited durability, with the average dressing change happening every 50 hours -- far less than the recommended seven days. Only three percent of the dressings lasted the full seven days, and 75 percent lasted less than 48 hours.2

Through rounding, our IV therapy team observed that our dressing integrity was less than satisfactory, but we needed to conduct a point prevalence assessment to quantify this. Another hospital within our system, the Hospital of Central Connecticut, had experienced improved dressing adherence with the use of a gum mastic liquid adhesive. In 2019, we began to consider this product as a potential solution that could minimize the dressing disruptions that were putting our patients at risk.

EVIDENCE-BASED LIQUID ADHESIVE

Widely used in operating rooms since 1965, the safety and efficacy of gum mastic liquid adhesive is well-documented. It is clinically proven to enhance the adhesive power of a variety of tapes and dressings, performing better than tincture of benzoin or no pretreatment at all.3,4 The non-water soluble, latex-free adhesive is shown to be well-tolerated with a low risk of adverse reactions.4

More recently, as researchers began to explore the use of gum mastic liquid adhesive in vascular access, they found that it provides effective securement and CONTINUED ON NEXT PAGE

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improves dressing integrity from current standards of care. A 2019 study of more than 30,000 dressings applied with gum mastic reported that 96 percent were fully intact upon direct observation.5 Another study showed that impaired peripherally inserted central catheter (PICC) dressings decreased by 67 percent and impaired intrajugular (IJ) dressings by 92 percent.6 This is particularly impressive considering that IJs are used in a notoriously challenging anatomical location. adherence and the benefits of gum mastic liquid adhesive for improving dressing integrity. While previous standards address the importance of securement, there were no specific recommendations for evidence-based best practices. In the most recent update, INS specifically recommends evaluating the benefits of gum mastic liquid adhesive in order to ensure dressings remain intact, as well as using audit and feedback to implement protocol changes in VAD dressing care and maintenance.10

The adhesive’s durability in moist or moisture-prone areas ensures secure placement over an extended period of time, reducing the likelihood of dressing displacement or device dislodgement. Studies have linked the benefits of this lasting occlusive barrier to a reduction in central line associated blood stream infection (CLABSI) rates. Browne et al. reported that use of gum mastic completely eliminated CVC dressing disruptions and reduced CLABSI rates by 76 percent.7 Another facility reported a decrease in CLABSI rates after adding gum mastic to all central line dressing change kits.8

DRASTIC IMPROVEMENTS FROM CARDIAC ICU TO HOSPITAL-WIDE

With such a strong body of evidence, we wanted to see if improving our dressing integrity with gum mastic liquid adhesive could help us minimize infection risks and protect our patients.

In November 2019, we initiated a trial to measure its impact on central line dressings in the cardiac intensive care unit (ICU).

Gum mastic is also compatible with chlorhexidine (CHG), which was a major factor in our selection.9 Both CHG skin preparation and CHG-impregnated dressings are an important part of Hartford Hospital’s infection control practices, as numerous organizations recommend these measures to reduce infection risks. We liked that the gum mastic could enhance adhesion of the CHG-impregnated dressings without diminishing the efficacy of the antimicrobial agent. In the 2021 Infusion Therapy Standards of Practice, INS recognizes both the importance of VAD dressing We began with four days of observational data collection that included bedside rounding VAD site assessments to note the state of the dressings. We categorized “non-intact dressings” in three ways -- edges lifted, partially detached or completely detached. The assessment confirmed our anecdotal observations of suboptimal dressing adherence, as 77 percent of dressings were non-intact. After two weeks of staff training and another four days of post-implementation observation, we saw a marked improvement in our dressing adherence. We reduced the incidence of dressing disruptions to just 36 percent, with zero dressings either partially or completely detached. In addition, the staff were very enthusiastic about the product. Prior to implementation, IJ dressings required almost daily changes; with the gum mastic liquid adhesive, a majority of IJ dressings lasted the full seven days.

It also became clear that these clinical benefits would translate to cost savings CONTINUED ON NEXT PAGE

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for our institution. This includes minimizing the direct costs associated with premature dressing changes or failed lines due to catheter dislodgement. Soft cost savings include less nursing time spent on unplanned dressing changes, as well as a reduction in excess costs and decreased reimbursement associated with CRBSIs.

With concrete evidence of the clinical and economic benefits, the administration quickly approved a hospital-wide quality initiative for use of the gum mastic liquid adhesive with all central lines. Though COVID-19 delayed getting into our CVC kits by a year due to manufacturing delays, the adhesive was added to all CVC Dressing Change Kits by March 2021 and is now being used in all acute care facilities affiliated with Hartford Healthcare.

When we conducted a whole-house audit to confirm staff compliance, we saw continued improvements in our dressing adherence rates. Of the 126 VAD sites assessed, 79 percent of dressings were fully intact, compared to just 24 percent in the initial trial.

NEXT STEPS - IMPROVING PIV DRESSING INTEGRITY

While gum mastic liquid adhesive is now standard of care for central line dressings at Hartford Hospital, we continue to use it on an as-needed basis for PIV dressings. However, we are developing the protocol for a randomized controlled clinical trial to quantify the impact of the liquid adhesive on PIV dressing integrity. If the results are similar to what we observed with central line dressings, it may eventually become standard of care for PIV catheter securement as well.

This research is particularly timely given the recent recommendations from the patient safety organization, ECRI. They included peripheral vascular harm on its list of Top 10 Patient Safety Concerns of 2021.11 PIVs are the most commonly used invasive device in hospitals, but with a failure rate of 35-50 percent, this seemingly routine procedure is putting patients at risk of serious complications.

ECRI acknowledges the role VAD dressings play in protecting patients from peripheral vascular harm. In order to address PIV harm at an organizational level, they recommend obtaining data from in-depth schedule dressing assessments, as well as using proven technology to facilitate proper catheter securement -- much like we’ve done with central lines at Hartford Hospital.

With the shift to value-based care models, all healthcare organizations are searching for ways to reduce infections while providing better outcomes, higher quality and lower healthcare costs. Our experience has shown that using gum mastic liquid adhesive to improve dressing adherence is a simple and effective strategy to achieve that.

REFERENCES

1. Timsit JF, Bouadma L, et al. Dressing disruption is a major risk factor for catheter-related infections. Crit Care Med. 2012 Jun; 40(6): 1707-14. doi:10.1097/CCM.0b013e31824e0d46.

2. Richardson A, Melling A, Straughan C. Central venous catheter dressing durability: an evaluation. 2015; 16: 256-61.

3. Patel N, Smith CE, et al. The influence of tape type and of skin preparation on the force required to dislodge angiocatheters. Can J Anaesth. 1994 Aug; 41(8): 738-41. PMID: 7923524.

4. Lesesne CB. The postoperative use of wound adhesives. Gum mastic versus benzoin, USP. J Dermatol Surg Oncol. 1992 Nov; 18(11): 990. PMID:1430556.

5. DeVries M, Sarbenoff J, et al. Improving Vascular Access Dressing Integrity in the Acute Care Setting, Journal of Wound, Ostomy and Continence Nursing: June 28, 2021 - Volume Publish Ahead of Print - Issue - doi: 10.1097/WON.0000000000000787

6. Pullen D. Quality Improvement Initiative to Improve Dressing Adherence Reveals Improved Dressing Adherence Observations on a Before-After Analysis. Poster presented at: AVA Annual Scientific Meeting, September 7-10, 2014.

7. Browne B, Moffo H. Quality improvement initiative results in fewer dressing disruptions and improved adherence to best practices. Poster presented at: Greater Cincinnati AACN Trends in Critical Care. April 8, 2016.

8. Bortz A, Hardinger K, Peltzer J. Impact of implementing Mastisol® in central line dressing changes on central line-associated bloodstream infections in progressive care units: a quality improvement project. Presented at: Magnetizing KC Symposium, February 24, 2015.

9. Ryder M, Duley C. Evaluation of compatibility of gum mastic liquid adhesive and liquid adhesive remover with an alcoholic chlorhexidine skin preparation. Infus Nurs. 2017; 40(4): 245-252.

10. Gorski, LA, Hadaway, L, Hagle, ME, et al. Infusion Therapy Standards of Practice. 8TH J Infus Nurs. Revised 2021.

11. ECRI (2021) Top 10 Patient Safety Concerns 2021. https://www. ecri.org/top-10-patient-safety-concerns-2021